What is the treatment approach for a patient with Respiratory Syncytial Virus (RSV) infection?

Treatment for RSV Infection

Primary Treatment Approach

RSV infection is managed primarily with supportive care—there is no specific antiviral treatment for most patients, and the focus should be on maintaining adequate hydration, providing supplemental oxygen when oxygen saturation falls persistently below 90%, and using antipyretics (acetaminophen or ibuprofen) for fever control. 1, 2, 3

Core Supportive Measures

• Hydration assessment and maintenance is essential for all RSV patients, with nasogastric or intravenous routes used if oral intake is inadequate 1, 2, 4
• Supplemental oxygen should be provided if oxygen saturation falls persistently below 90% in previously healthy infants, with the goal of maintaining SpO2 >90-92% 1, 2, 3
• Antipyretics (acetaminophen or ibuprofen) can be used for pain or fever management 1, 3
• Nasal saline irrigation may provide symptomatic relief in adults with upper respiratory symptoms 1

What NOT to Use: Critical Pitfalls

Ineffective Therapies to Avoid

• Palivizumab has NO therapeutic benefit for treating established RSV infection—it is FDA-approved only for prevention in high-risk infants and should never be used as treatment 1, 2, 3, 5
• Corticosteroids should NOT be used routinely in bronchiolitis management 1, 3, 4
• Bronchodilators should NOT be continued without documented clinical improvement 1, 3, 4
• Ribavirin should NOT be used routinely in children with bronchiolitis—its use is restricted to severely immunocompromised patients, hematopoietic stem cell transplant (HSCT) patients, and mechanically ventilated infants with documented severe RSV infection 1, 3
• Antibacterial medications should only be used when specific indications of bacterial co-infection exist 1, 3, 4
• Chest physiotherapy is not recommended 4
• Nebulized hypertonic saline is not recommended 4

High-Risk and Immunocompromised Patients: When Antiviral Therapy Is Indicated

Ribavirin Administration

For HSCT recipients and severely immunocompromised patients with RSV lower respiratory tract infection, ribavirin is the primary antiviral option, administered as aerosolized, oral, or intravenous formulations. 1

Aerosolized Ribavirin

• Primary option for HSCT patients with RSV lower respiratory tract infectious disease (LRTID) or those at high risk for progression 1
• FDA-approved for hospitalized infants and young children with severe lower respiratory tract RSV infection, though use should be limited to truly severe cases 1
• Also indicated for mechanically ventilated patients with documented severe RSV infection 1

Systemic Ribavirin (Oral or IV)

• Dosing schedule: 1
  • Day 1: 600 mg loading dose, then 200 mg every 8 hours
  • Day 2: 400 mg every 8 hours
  • Day 3 onward: Increase to maximum of 10 mg/kg body weight every 8 hours
  • Renal adjustment: For creatinine clearance 30-50 mL/min, maximum 200 mg every 8 hours
• Oral ribavirin may be an effective and easier-to-administer alternative that can reduce progression to lower respiratory tract infection and mortality in immunocompromised patients 1

Monitoring for Ribavirin Adverse Events

• Aerosolized form: Monitor for claustrophobia, bronchospasm, nausea, conjunctivitis, and declining pulmonary function 1
• Systemic form: Monitor for hemolysis, abnormal liver function tests, and declining renal function 1
• Environmental precautions: Avoid exposure in pregnant healthcare workers due to teratogenic effects 1

Combination Therapy for HSCT Patients

• Consider combining ribavirin with intravenous immunoglobulin (IVIG) or anti-RSV-enriched antibody preparations for allogeneic HSCT patients with RSV LRTID or at high risk for progression 1

Timing Considerations

• Defer conditioning therapy for patients with RSV respiratory tract infection planned for allogeneic HSCT 1
• Consider deferring chemotherapy for patients with RSV infection scheduled for hemato-oncological treatment 1

High-Risk Populations Requiring Ribavirin Consideration

• HSCT recipients with RSV infection require more aggressive management, including consideration of ribavirin therapy 1
• Solid organ transplant recipients with RSV infection may require more intensive care, including supplemental oxygen and close monitoring 1
• Patients with active chemotherapy for malignancy and RSV infection should be closely monitored for respiratory complications and considered for ribavirin therapy 1
• HIV-infected patients with significant immunosuppression who develop RSV infection should receive prompt treatment, including consideration of antiviral therapy 1
• Patients on chronic immunosuppressive therapy (including high-dose corticosteroids or biologics) who develop RSV infection should be closely monitored and considered for ribavirin therapy 1

Respiratory Support and Escalation of Care

Oxygen Therapy and Ventilation

• High-flow nasal oxygen (HFNO) may be considered in selected patients with hypoxemic respiratory failure, though patients should be in a monitored setting with experienced personnel capable of intubation 1, 6
• Non-invasive ventilation (NIV) is generally NOT recommended for RSV infection due to high failure rates and risk of aerosol generation 1
• Early intubation and invasive mechanical ventilation should be considered if respiratory distress worsens or oxygen requirements cannot be met with standard supplementation 1

ICU Transfer Criteria

Consider transfer to high dependency or intensive care if: 1, 2

• Patient fails to maintain SaO2 >92% in FiO2 >60%
• Patient is in shock
• Severe respiratory distress with rising PaCO2 (>6.5 kPa)
• Development of apnea or persistent grunting
• Worsening respiratory distress despite supplemental oxygen
• Oxygen requirement of FiO2 ≥0.50

Monitoring

• Monitor mental status as part of vital signs in patients with RSV infection 1
• Continuous SpO2 monitoring is not routinely needed as the child's clinical course improves 1
• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring as oxygen is being weaned 1

Hospitalization Criteria

Indications for Admission

Hospitalize if: 2, 3

• Hypoxemia (SpO2 persistently <90%)
• Signs of severe respiratory distress
• Inability to maintain adequate oral intake
• Underlying high-risk conditions (prematurity, chronic lung disease, congenital heart disease, immunocompromised status)
• Infants with severe respiratory distress, inability to maintain hydration, or oxygen saturation <90% despite supplemental oxygen

Most RSV hospitalizations occur in children under 5 years of age, with 75% occurring in infants younger than 12 months. 1, 2

Infection Control: Critical for Preventing Transmission

Hand Hygiene

Hand decontamination before and after direct patient contact is the single most important measure to prevent transmission. 1, 3

• Alcohol-based rubs are preferred if hands are not visibly soiled 1, 3
• Hand hygiene should be performed: before and after direct patient contact, after contact with objects near the patient, and after removing gloves 1

Additional Precautions

• Wear gloves while handling patients with confirmed or suspected RSV infection and when handling potentially contaminated fomites, with frequent changes to avoid spreading organisms 1, 3
• Wear gowns for direct contact with the patient 1
• Education of personnel and family members about prevention is essential 1
• Programs implementing strict hand hygiene and droplet precautions have decreased nosocomial RSV transmission by 39-50% 1

Prevention Strategies

Prophylaxis with Palivizumab (NOT Treatment)

Palivizumab is indicated ONLY for prevention, not treatment: 1, 5

• Infants born before 29 weeks gestation who are younger than 12 months at the start of RSV season
• Infants with bronchopulmonary dysplasia (BPD) that required medical treatment within the previous 6 months and who are 24 months of age or younger
• Infants with hemodynamically significant congenital heart disease (CHD) and who are 24 months of age or younger
• Patients with Severe Combined Immunodeficiency (SCID) or suspected SCID should receive prophylaxis during RSV season

Palivizumab reduces RSV hospitalization by 45-55% in high-risk populations. 1

Universal Prevention Measures

• Avoid tobacco smoke exposure completely—it is a controllable risk factor that increases RSV hospitalization risk 1
• Limit exposure to crowds and group childcare during RSV season (November through March in most regions) 1
• Keep infants away from sick contacts and situations where exposure to infected individuals cannot be controlled 1
• Encourage breastfeeding to potentially decrease the risk of lower respiratory tract disease 1, 2
• Ensure influenza vaccination for the infant (starting at 6 months) and all household contacts 1

Newer Prevention Strategies

• Nirsevimab, a long-acting monoclonal antibody, is recommended for all infants <8 months entering their first RSV season 1
• RSV vaccines are indicated for people aged ≥50 years with risk factors and all persons aged ≥60 years 1, 7
• If vaccine availability is limited, priority should be given to individuals aged ≥75 years and those aged ≥50 years with risk factors 1

Diagnostic Testing Considerations

When to Test for RSV

• High-risk populations (immunocompromised individuals, transplant recipients, those with severe underlying cardiopulmonary disease) may require testing for risk stratification 1
• Infants receiving palivizumab prophylaxis who develop bronchiolitis should undergo RSV testing to determine if breakthrough RSV infection occurred, which would warrant discontinuation of further prophylaxis 1
• Febrile infants ≤60 days old being evaluated for serious bacterial infection should undergo RSV testing, as a positive result reduces (but does not eliminate) the risk of concurrent bacterial infection 1
• Routine outpatient bronchiolitis cases where management will be supportive regardless do not require RSV testing 1
• Rapid diagnostic testing should be performed to document RSV infection, especially during RSV season, for pediatric patients and immunocompromised adults with respiratory illness 3